Psychedelic-Assisted Therapy and Primary Care

Primary care is at the front lines of mental healthcare and may soon be at the forefront of psychedelic-assisted therapy. For more on this topic, we invite you to watch our webinar “Psychedelics and Primary Care,” which was moderated by the author. 

By Darron Smith

Primary care medicine is the bedrock of the healthcare system: it plays a vital role in preventing, diagnosing, and treating a wide range of medical conditions. Primary care providers (PCPs), including physicians, physician associates, and nurse practitioners, are gatekeepers of America’s tattered mental healthcare system. PCPs often have the first point of contact with patients and their families, allowing them to gauge their emotional health through the course of the doctor-patient relationship. Up to 75% of primary care visits have mental or behavioral health presentations (Cunningham, 2009). Cancer, HIV/AIDS, diabetes, substance use disorders, and tobacco use are all examples of chronic disease that requires attention to mental and behavioral health co-morbidities (McGough et al., 2016).  

There are several reasons why PCPs are so important in mental healthcare. Fundamentally, PCPs are often the only healthcare providers that see their patients throughout the life cycle from birth until death. This means they are uniquely positioned to identify the symptoms of mental illness early on. Additionally, PCPs are trained to recognize the symptoms of mental and behavioral health disorders. They are familiar with the resources available to help patients with mental illness, and they are responsible for treating or referring patients to mental health specialists when necessary. And ultimately, PCPs can play a role in preventing and managing mental health problems through psychoeducation. They can help patients regulate stress, contend with difficult life events, and develop healthy coping mechanisms. It is important to recognize that treatment in a primary care setting allows for the continuity of care with overall better health outcomes (Funk et al., 2008). 

Anxiety, depression, and post-traumatic stress disorder (PTSD) can be effectively treated by a class of medications called selective serotonin reuptake inhibitors (SSRIs); however, they do not work for everyone. SSRIs have a failure rate of at least 30% from ineffective treatment to intolerance of side effects (Zamorski & Albucher, 2002). Some people find that SSRIs do not help their symptoms or that they make their symptoms worse. Others experience side effects such as nausea, vomiting, diarrhea, and sexual problems. The FDA has not approved any new medications for the treatment of PTSD since 2001. Paxil (paroxetine) and Zoloft (sertraline)—both SSRIs—are the only two medications approved by the FDA to treat PTSD. 

In recent years, psychedelic medicines (such as MDMA, psilocybin, and LSD) have demonstrated considerable potential as adjuvants in the treatment of PTSD along with other mental illnesses and addiction. There has been a growing body of scientific evidence supporting the therapeutic use of psychedelics. Many of these studies demonstrate that psychedelics can effectively alleviate the symptoms of PTSD, depression, anxiety, and substance use disorders. These mind-altering substances can also help people explore their inner selves while removing the ego. 

Psychedelic-assisted therapy (PAT) is a form of treatment that uses psychedelics to aid in the healing and recovery from mental illness, including co-occurring addiction. Such therapy is often administered under the supervision of a trained therapist or facilitator in a safe and supportive atmosphere. The therapist/facilitator assists the individual in exploring their thoughts, feelings, and experiences in a manner that enables restoration from trauma. It cannot be overstated, however, that psychedelics are not a panacea. Indeed, studies consistently demonstrate the importance of a safe location where set and setting are paramount along with trained facilitators. Participant improvement in many studies had much to do with intentionality, preparation, and solid integration¹“Psychedelic integration is a process in which the patient integrates the insights of their experience into their life” (Gorman et al., 2021)..

Considering the FDA’s expected approval of MDMA in 2024, it is crucial that primary care physicians and other prescribers be familiar with this molecule as a serious therapeutic option (Kargo, 2020). In fact, MDMA and psilocybin are currently in use in clinical trials and were designated “breakthrough therapies” for PTSD and treatment-resistant depression, respectively, by the FDA in 2018. At the very least, patients will be asking their primary care providers about these therapies and how to access them. Primary care offices could move to adopt this innovative care as first responders in the fight against mental illness. It is conceivable that in the not-too-distant future, primary care practices could become the hubs for such work in a thoughtful manner. This would require a section of the primary care office to be retrofitted to create a space where set and setting²“Set is the mind-set or expectation one brings to the experience, and setting is the environment in which it takes place” (Pollan, 2018). are given high priority and where patients feel safe while journeying. Along with primary care providers, the office would benefit from a PAT-trained therapist as well, who would be integral in conducting the preparation and post-treatment integrative sessions. This model would make access to PATs more equitable, particularly for black, indigenous, and people of color.  

There are major hurdles to consider before such treatment becomes a reality in the American healthcare system. For starters, there is no guarantee that insurance will reimburse for PAT, although efforts are underway with organizations like BrainFutures and APPA along with the FDA advisory panels to address this very topic. Additionally, PCPs would need to undergo specific training to practice psychedelic-assisted therapy safely. New psychedelic research centers, such as the University of Washington’s Center for Novel Therapeutics in Addiction Psychiatry, intend to explore more comprehensive clinical uses and can be a great resource for community providers. This center will also offer practical training for medical school residents, physician associate students, and nurse practitioner students who will likely prescribe this medication.  

If there were ever a time in psychiatry for better tools, this seems to be the proper moment to gain the upper ground on mental illness. If you are struggling with a mental health problem, it is important to see your PCP. They can help you identify the problem and get the help you need. They can also provide support and guidance as you work to improve your mental health.

Biography

Darron T. Smith has accepted a position as an associate professor in the Department of Family Medicine at the University of Washington. He is a physician assistant and US Army veteran with over twenty years of healthcare-related experience as a physician assistant educator and mental health treatment provider in psychiatry. Dr. Smith has trained with MAPS’ MDMA-assisted therapy. His research and scholarship examine US-based systems of racial oppression and systemic inequality found in all societal domains, including healthcare, the family (transracial adoption), healthcare disparities, religion, sport, culture, and politics. Dr. Smith’s current research and practice intertwine the study of applied neuroscience, race-based trauma, and mental illness by looking at the impact of EEG biofeedback versus MDMA-assisted psychotherapy on brainwave activity in individuals with racial trauma (PTSD) using EEG technology. He is Co-Director at the Center for Novel Therapeutics in addiction psychiatry at the University of Washington. He is also on a Board of Directors at the American Psychedelic Practitioners Association and is an advisor to Chacruna Institute. Follow Darron on Twitter at @drdarronsmith.

References 

Cunningham, P.J. (2009) Beyond Parity: Primary Care Physicians’ Perspective on Access to Mental Health Care: More PCPs have trouble obtaining mental health services for their patients than have problems getting other specialty services. Health Affairs, 28(Suppl 1), w490-w501 

Funk M, Saraceno B, Drew N, Faydi E. (Mar 2008). Integrating mental health into primary healthcare. Mental Health Family Medicine, 5(1), 5-8.

Gorman, I., Nielson, E. M., Molinar, A., Cassidt, K., & Sabbagh, J. (2021). Psychedelic harm reduction and integration: A transtheoretical model for clinical practice. Frontiers in Psychology, 12. 

Kargo, R. (2020, Mar 2). Psilocybin therapeutic research: The present and future paradigm. ACS Medicinal Chemistry Letters, 11(4), 399–402. 

McGough, P. M., Bauer, A. M., Collins, L., & Dugdale, D. C. (2016). Integrating behavioral health into primary care. Population Health Management, 19(2), 81-87.

Pollan, M. (2018). How to change your mind: What the new science of psychedelics teaches us about consciousness, dying, addiction, depression, and transcendence. New York: Penguin Press.

Zamorski, M., & Albucher, R. (2002). What to do when SSRIs fail: Eight strategies for optimizing treatment of panic disorder. American Family Physician, 66(8), 1477-1485.